Feature

The long road to a healthy north

Official acknowledgement of Scotland’s appalling health record and widening health inequality should focus the minds of the new Scottish Parliament, says Dick Barbor-Might

In 1983 Gordon Brown and Robin Cook edited a book subtitled Poverty and deprivation in Scotland.* In it, Gordon Brown blamed Conservative government policy for the fact that the number of poor in the UK was rising dramatically. ‘As one confidential government document made clear, redistribution of income from the rich to the poor is “not among the government’s objectives”. The real incomes of the poor have simply been cut,’ he wrote. On social justice he was just as clear, arguing that the proper goal of public policy should be equality of outcome, or income redistribution, rather than Mrs Thatcher’s favoured goal, equality of opportunity.

Of course, both authors are now leading members of a New Labour government which has the responsibility for reducing those inequalities that they so effectively exposed when in opposition.

In Scotland as elsewhere in the UK, ministers have brought the facts into the light of day. Some of the most telling statistics appeared in Working together for a healthier Scotland, the green paper on public health published in February 1998, just a year before the Scottish Office published the white paper, Towards a healthier Scotland. Many people share the view of Steve Platt of Edinburgh University’s research unit for health and behavioural change, that it is like a breath of fresh air to read government documents that give things their proper names and frankly acknowledge the human costs of inequality.

In Scotland these costs are huge. A far larger proportion of the population lives in poverty than in England and Wales. The prosperity that is so much in evidence in the centre of Edinburgh, the site of Scotland’s new Parliament, is hardly to be found in the city’s perimeter estates, in working class areas across the country that have been devastated by factory, mine or shipyard closures or in some of the remote rural communities.

Only 6 per cent of the Scottish population live at the level of affluence enjoyed by a fifth of the population in England and Wales, while 18 per cent are living at a level of deprivation experienced by fewer than one in 20 people in England and Wales. In terms of mortality, Scotland’s record is worse than England and Wales, and many other industrial countries. Much of the excess of premature deaths in Scotland is the result of inequality. The health divide widened in the ten years from 1981 to 1991, with the standardised mortality ratio in the most deprived areas rising from 120 per cent to 162 per cent above the rate in the most affluent areas. In 1991 the mortality rate among people under 65 in the most deprived areas was more than double that in the most affluent areas. Shockingly, Glaswegians aged 15-64 in the early 1990s had a higher death rate than did people in the same age group in Bristol in the early 1950s.

One litmus test of the government’s political will to tackle the health divide was the Scottish white paper on public health, published in February 1999. While it has good things in it, it also disappoints. As many critics have pointed out, the whole approach is still very medical in nature. It is the NHS rather than local authorities that are put in the driving seat of implementation. This is all the more odd since the white paper acknowledges that reducing inequality is to be achieved not just through improvements in lifestyles but also in life circumstances – social inclusion, jobs, income, housing, education and the environment. Yet it is local government, not the NHS, that has a major responsibility for these.

An explicit target for reducing inequalities and an indication of the inputs that would be required to bring about improvements in life circumstances are both notable by their absence in the white paper. Is this deliberate? The question needs to be asked, especially since ministers are not short of resources for policy research: the Scottish Office has its own working group on measuring and targeting health inequalities.

Many people would rather still give the government the benefit of the doubt than give up the hopes nurtured through long years of Conservative reign. To be fair, there are hopeful signs of good intention: for while Gordon Brown may nowadays espouse equality of opportunity rather than equality of outcome, he has pushed forward some policies which begin to look like ‘redistribution by stealth’.

And the new factor in all of this is the Scottish Parliament. It is too soon to say whether any, or many, of the new MSPs will take up the issue of health inequality. They may find it easier to focus on health services which, unlike broad economic and fiscal policy, are a direct responsibility of the Scottish Parliament and are prized by the public. But if they do, they cannot expect their deliberations to have very much impact on Scotland’s state of health.

Gordon Brown, Robin Cook (eds). Scotland: the Real Divide — poverty and deprivation in Scotland. Mainstream Publishing, 1983.